A Bundle for Treatment after Cardiac Arrest: Protective Ventilation, Temperature Control and Stable Hemodynamics
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1 A Bundle for Treatment after Cardiac Arrest: Protective Ventilation, Temperature Control and Stable Hemodynamics PAOLO PELOSI, MD, FERS Department of Surgical Sciences and Integrated Diagnostics (DISC) University of Genoa IRCCS AOU San Martino IST Genoa, Italy
2 Conflicts of Interest I declare NO conflicts of interest
3 Natural course of neurological recovery following cardiac arrest Patil KD et al. Circ Res Jun 5;116(12): Cardiac arrest Brain stem recovery Recovery of cortical function COMA Vegetative state Brain Dead hours days ( weeks)
4 Early Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest Hasselqvist-Ax I. et al. N Engl J Med 2015;372:
5 Outcomes for out-of-hospital cardiac arrests across 7 countries in Asia: PAROS study Eng Hock Ong M et al Resuscitation 2015 (Epub Ahead of Print)
6 Adrenaline and Vasopressin during CPR in Out-of-Hospital Cardiac Arrest
7 Effects of Epinephrine on Hospital Survival During CPR Vargas M et al. Annual Update in Intensive Care and Emergency Medicine, Springer Verlag, J.-L. Vincent (ed.), 2015 pp Low-dose epinephrine was defined as 1mg, 0.02 or 0.01 mg/kg High-dose epinephrine was defined as 0.1 or 0.2 mg/kg, 5mg, 7mg, 5 15 mg
8 Effects of Epinephrine on Hospital Survival During CPR Vargas M et al. Annual Update in Intensive Care and Emergency Medicine, Springer Verlag, J.-L. Vincent (ed.), 2015 pp
9 Effects of Vasopressin vs Adrenaline on Hospital Survival During CPR Vargas M et al. Annual Update in Intensive Care and Emergency Medicine, Springer Verlag, J.-L. Vincent (ed.), 2015 pp Vasopressin may be administered in a single dose of 40 IU or up 2 doses of 40 IU
10 Mild to Moderate Hypothermia in Out-of-Hospital Cardiac Arrest
11 Pre-Hospital Hypothermia: Survival to Hospital Discharge Vargas M et al. Annual Update in Intensive Care and Emergency Medicine, Springer Verlag, J.-L. Vincent (ed.), 2015 pp
12 Effects of in-hospital low targeted temperature after out of hospital cardiac arrest: A systematic review with meta-analysis of RCTs Vargas M et al. Resuscitation Jun; 91:8-18
13 Effects of in-hospital low targeted temperature after out of hospital cardiac arrest: A systematic review with meta-analysis of RCTs Vargas M et al. Resuscitation Jun; 91:8-18
14 Normoxia, Hypoxia, Hyperoxia and CO 2 in Out-of-Hospital Cardiac Arrest
15 Effects of Normoxia vs Hyperoxia (>300 mmhg) and Hypoxia (< 60 mmhg) on In-hospital Mortality Sutherasan Y et al. Minerva Anestesiol Jan;81(1):39-51
16 Effect of Normocapnia and Hypocapnia on Poor Neurological Outcome (Adults and Pediatrics) Effect of Normocapnia and Hypercapnia on Poor Neurological Outcome (Adults and Pediatrics)
17 Arterial carbon dioxide tension and outcome in patients admitted to the intensive care unit after cardiac arrest Schneider AG et al. Resuscitation 84 (2013)
18 Hemodynamics and Vasopressor Support in Out-of-hospital Cardiac Arrest
19 Hemodynamics and vasopressor support at two target temperatures after cardiac arrest Bro-Jeppesen J et al. Crit Care Med Feb;43(2):318-27
20 Hemodynamics and vasopressor support at two target temperatures after cardiac arrest Bro-Jeppesen J et al. Crit Care Med Feb;43(2): PREDICTORS OF NEED FOR HIGH VASOPRESSORS
21 Out-of-hospital Cardiac Arrest and Survival to Hospital Discharge: A Series of Systemic Reviews and Meta-analyses Vargas M et al. Annual Update in Intensive Care and Emergency Medicine, J.-L. Vincent (ed.) Springer International Publishing Switzerland 2015; pp
22 Ventilatory Management in Out-of-Hospital Cardiac Arrest
23 Management and Outcome of Mechanically Ventilated in Patients after Cardiac Arrest Sutherasan Y et al. Crit Care May 8;19:215 All subjects N=812 Mean(SD) Cohort 1998 N=100 Mean(SD) Cohort 2004 N=239 Mean(SD) Cohort 2010 N=473 Mean(SD) P value Tidal volume/kg 7.1(2.0) 8.86(2.0) 7.4(1.9) 6.7(1.8) <0.001 Tidal volume /kg 8.3(2.0) No data 9.04(2.3) 7.95(1.7) <0.001 PBW RR/min 18.8(6.0) 16.9(4.0) 17.9(6.4) 19.4(6.0) <0.001 Minute ventilation 9.6( 3.1) 10.6( 2.8) 9.7( 3.3) 9.4( 3.0) <0.001 (L/minute) PIP(cmH 2 0) 25.5(8.0) 29.1(7.5) 27.1(7.9) 24.1(7.9) <0.001 P Plateau(cmH 2 0) 20.6(6.2) 22.7(3.7) 21.5(6.5) 19.5(6.3) <0.001 PEEP(cmH20) 5.8(3.4) 3.5(3.1) 4.8(4.0) 6.5(2.7) <0.001 PaO 2 (mmhg) 116.2(59.6) 114.3(43.7) 121.8(65) 113.9(59) <0.001 PaO 2 /FiO 2 ratio 247.7(107.3) 238.4(95.1) 242.2(95.1) 252(114.1) <0.05 PaCO 2 (mmhg) 39.3(11.0) 37.3(7.4) 38.8(10.4) 39.8(11.7) <0.001 pha 7.39(0.1) 7.41(0.08) 7.39(0.1) 7.39(0.1) <0.001
24 Management and Outcome of Mechanically Ventilated in Patients after Cardiac Arrest Sutherasan Y et al. Crit Care May 8;19: Mode of ventilation and days of use per 1,000 days of invasive mechanical ventilation from 1998, 2004 and A/C SIMV SIMV_PS PSV PCV PRVC BIPAP-APRV Other NIV
25 Management and Outcome of Mechanically Ventilated in Patients after Cardiac Arrest Sutherasan Y et al. Crit Care May 8;19:215 All subjects Cohort 1998 Cohort 2004 Cohort 2010 P value N=812 N=100 N=239 N=473 ARDS, no (%) 68(8.4) 6(6) 14(5.9) 48(10.1) 0.1 Acquired ICU pneumonia, 43(5.3) 14(14) 11(4.6) 18(3.8) 0.00 no (%) Sepsis, no (%) 138(17 13(13) 24(10) 101(21.4) 0.00 Barotrauma, no (%) 15(1.8) 2(2) 6(2.5) 7(1.5) 0.62 Cardiovascular failure, 543(66.9) 33(33) 162(67.8) 348(73.6) 0.00 no (%) Renal failure, no (%) 275(33.9) 23(23) 79(33.1) 173(36.6) 0.03 Hepatic failure, no (%) 94(11.6) 2(2) 38(15.9) 54(11.4) 0.00 Haematological failure, 11(11) 13(5.4) 50(10.6) 74(9.1) 0.06 no (%) Glasgow coma scale(sd) 8.7(5.2) No data 8.5( 5.2) 7.5( 4.6) 0.00
26 Logistic regression analysis for 28 days mortality Sutherasan Y et al. Crit Care May 8;19:215 Variable Logistic regression Odd ratio(95%ci) P value Age,years 1.01( ) 0.01 PaO mmhg (ref) PaO2<100 mmhg PaO2>200 mmhg 1.54( ) 1.36( ) pha (ref) Acidosis(pHa<7.35) Alkalosis(pHa>7.45) 1.31( ) 1.15( ) Cardiovascular Failure/Shock (yes/no) 1.47( ) 0.02 Renal Failure(yes/no) 1.31( ) 0.15
27 Association between V T size, duration of ventilation, and sedation needs in patients without ARDS: an individual patient data meta-analysis Serpa Neto A. et al. Intensive Care Med (2014) 40: PEEP 5 cmh 2 O
28 Lung protective ventilation with low V VENTILAÇ Ã O PROTETORA T and the NA UTI occurrence of pulmonary complications in non ARDS patients: a systematic review and meta-analysis Serpa Neto A. et al. Crit Care Med 2015 Jul 15 [Epub Ahead of Print] 2,184 patients from 7 investigations trend to shorter stay in hospital less ARDS Survival) PEEP 5 cmh 2 O
29 PROVENT PROTECTIVE VENTILATION IN CRITICALLY ILL PATIENTS WITHOUT ARDS An International Multicenter Observational Study
30 RANDOMIZED CONTROLLED TRIALS PRotective VENTilation in Patients Not Fulfilling the Consensus Definition for Moderate or Severe ARDS (PReVENT-NL) Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA). NCT NLM Identifier: NCT Pts without moderate or severe ARDS: V T 4 6 vs ml/kg PBW ( Preventive Strategies in Acute Respiratory Distress Syndrome (ARDS) (EPALI) Corporacion Parc Tauli. NCT NLM Identifier: NCT Pts without ARDS: V T 6 vs. 8 ml/kg PBW
31 Lung Ultrasound and Transcranial Doppler in Out-of-Hospital Cardiac Arrest
32 Ultrasonography in ICU: Lung, Heart, & Volemia Pelosi P et al. Anesthesiology 117(4): , 2012 Corradi F et al. Respir Physiol & Neurobiol 187: (2013) Corradi F et al. Curr Opin Crit Care Feb;20(1): Corradi F et al. Biomed Res Int. 2015: (2015)
33 Optic Nerve Sheat Ultrasound Ball L, Corradi F et al. ICU Management 12(2): 30-33, 2012 Pelosi P et al. Anesthesiology 117(4): , 2012
34 Transcranial Doppler after Cardiac Arrest Sutherasan Y et al. Minerva Anestesiol Jan;81(1):39-51 Median Cerebral Artery(MCA) Anterior Cerebral Artery (ACA) Posterior Cerebral Artery (PCA) Hyperemia, hypocapnia Stenosis Normal Moderate ICH, Microangio Hypocapnia Severe ICH Cerbral Asistolia Mesencephalus Shadow Median Line Decresed pulsatility Low Pulsatility (physiolo) High Pulsatility Very high Pulsatility No cerebral flow Increase in Pulsatility Index = Increase in Distal Resistances PI = (Vs - Vd) / Vm
35 Preserved metabolic coupling and cerebrovascular reactivity during mild hypothermia after cardiac arrest Bisschops LL et al. Crit Care Med 2010 Jul;38(7): Doepp F et al. Resuscitation 2014; 85:
36 Prognosis Assessment after Out-of-Hospital Cardiac Arrest
37 Early Multimodal Outcome Prediction After Cardiac Arrest in Patients Treated With Hypothermia Oddo M et al. Crit Care Med Jun;42(6): Taccone FS et al. Critical Care 2014, 18:202 Clinical examination, Electroencephalography Reactivity, and Serum Neuron-Specific Enolase
38 Cognitive Function in Survivors of Out-of-Hospital Cardiac Arrest After Target Temperature Management at 33 C Versus 36 C Gisela L et al. Circulation 2015;131: The Frontal Assessment Battery is a screening battery for executive impairments
39 Core Temperature (Target 36 0 C) Seizures and Blood Sugar Control Transcranial Doppler Optic Nerve Sheath Ultrasound Trans-Cranial Doppler PaCO mmhg Oxygenation PaO 2 60 (100)-300 mmhg EVLWI - Thermodilution Technique - Lung Ultrasound MAP 65-75mmHg ±Vasoactive drugs Transthoracic Echocardiography Protective MV Low V T 6-8 ml/kg PBW PEEP of 5 cmh 2 O
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